Finding e-CDR Data – during and post hospitalization 1-29-15

advertisement
Finding e-CDR Data – during and
post hospitalization
1-29-15
New ! – CDR Report
• In order to monitor or trouble-shoot issues with
controlled substance documentation, a new
report is available in HED effective 2-3-15 – CDR
Med Status
• During an admission and for approx. 48 hrs. after
discharge, the report can be printed (but NOT
viewed) from within HED.
• From approx. 48 hrs. post discharge, the report
will be available to view or print from StarPanel.
(The report will be available for patients discharged after Feb. 3
when the report goes live so should be available post discharge for
some patients later this week.)
New CDR Report in HED
1. From Report link top of screen, click on
Transfer Reports.
2. CDR Med Status report will display.
3. Enter Start and End date/time for time range
you need to review.
4. Click Send.
5. HED reports print on Critical Printer (generally
printer by MR where HEO/Wiz order documents
print).
CDR Med Status
Hint: Sometimes this print dialogue box is buried behind other
windows on your computer so you may need to minimize other
windows before you see it.
To access New CDR Report in StarPanel > 48 hrs. post Discharge
1. Enter MR# to select patient.
2. Click on AllDocuments
3. Scroll down to find admission (look for light blue bar that
borders Inpatient Admission episodes of care.
4. Scroll to date of admission for hospitalization in question.
HED documents will display as a block under the name of the
Attending Physician on day of admission.
5. New CDR Med Status report will be listed with other reports
in this section.
CDR Med Status
StarPanel CDR Flowsheet
• Can access by entering MR # or by selecting patient
from a list by clicking on MR#
• CDR data does NOT age off Flowsheets like it ages off
of OPC. CDR data will remain for future reference
indefinitely.
• Limitations:
– Co-signatures not visible from CDR Flowsheet. (All other
required data is here.
– Flowsheets are not designed to be printed. You may be
able to capture needed information from a screen shot but
the Flowsheets are designed to be viewed on line and not
to be printed.
Click to
open all
Comments
Example of all Comments opened to read. (Note click to
hide hyperlink is available to close pop-up window when
you are done.)
Correcting CDR Documentation After the Fact
•
•
•
•
•
The original author of CDR documentation in HED may alter the documentation for
up to 30 hrs. after it’s entered (remove, modify).
Entries may also be co-signed in HED up to 30 hrs. after the original entry.
Late entries may be made up to 72 hrs. after the fact.
From the time of discharge, documentation can be entered (or corrected by
original author) from approx. 48 hrs. before charting is “closed”. [To access patient
during 48 hrs. post discharge to completed charting, pull up census for unit from
which patient was discharged and scroll to bottom of list to see all recently
discharged patients.]
When you cannot add to or correct charting in HED (because it’s been too long
since original entry or because charting is already closed post discharge), you may
document late entries in StarPanel.
To Make Late Entries in Starpanel …
Other sample entries:
1) I witnessed that 48.25 ml. remained in PCA syringe at change of shift
2) Completed/Denied for 7a-7p shift: 32/36
3) I witnessed that bag was empty after 48 ml. had infused.
1. Select patient from List or by
entering MR#.
2. Select Enter Data option
TypeNewDocument
3. Change date of service & time
to reflect time of e-CDR entry
that needs to be modified or
co-signed.
4. Type of Document = Nursing
Documentation
5. Indexing Comment = CDR
Late Charting Entry
6. Briefly enter documentation
change or statement about
observing waste or
participating in handover
communication about
quantity left to infuse & enter
full name and title.
7. Click Save as Final button.
Questions? Need Help?
• Call Help Desk –343-4357 or 3/HELP
• Ask for Systems Support Services on call.
Download